Acetabulum Fractures

Anatomy

Resisted hip flexion (hip flexor muscles)

Blood Supply Around the Pelvis

Pelvic/acetabulum fractures are usually the result of high energy injuries such as motor vehicle accidents or falling from an elevated place. Low grade energy causing a pelvic fracture can be associated with a pathological underlying condition.

Associated injuries include femur or any lower limb fractures, spine, chest and abdominal injuries.

There may be haemodynamic shock, especially when associated with polytrauma injuries.

Femur fractures. Exclude associated injuries with acetabulum/pelvic fractures as femur fractures can potentiate haemodynamic instability.

Causes:

High impact axial loading to the hip joint ± intra-articular fracture:

Motor vehicle accidents
Falling from an elevated position

Presentation:

Pain
Swelling
Deformity
Inability to walk
Shock
Associated abdominal, spine, limb injuries

Clinical Assessment:

Examination:

Use ATLS principles and stabilize patient
Assess local injury with assessment of skin bruising or open wounds and palpation of the affected area and the entire leg to exclude concomitant leg injuries
Skin: assess for local bruising including degloving Morel-Lavallee lesion
Exclude concomitant ipsilateral limb injuries and examine the leg neurovascular system
Exclude spine injuries
Bone tenderness
Deformity
Exclude bowel and bladder injuries and assess accordingly

Investigation:

X-ray views of pelvis: AP, inlet & outlet and Judet views
X-ray any associated injuries that may include the spine, femur/tibia and joints
CT scan for assessment of pelvic/acetabulum fracture configuration

Management:

Stabilize patient according to the ATLS guidelines
Maintain hydration
Initial pelvis stabilization with ring binder in in the unstable pelvis
External fixation can be used as an emergency, temporary fixation modality in the polytrauma, unstable patient requiring resuscitation and medical stabilization before definitive surgical management.
Definitive surgery with plate and screw fixation follow initial life threatening management
Surgery: early fracture stabilization and early mobilization decreases complication rates.

Pelvis X-ray

Pelvis: anterior to lateral view

X-ray AP pelvis

Pelvis: anterior to lateral view

Lateral view

Inlet views

Pelvis: anterior to lateral view

X-ray inlet pelvis view

Outlet views

Pelvis anterior to outlet view

X-ray outlet pelvis view

Judet views

Anterior view to Judet view

Judet pelvis view rotation to left

Pelvis: anterior to lateral view

Judet pelvis view rotation to right

Judet and Letournel Classification of Acetabular Fractures

Judet and Letournel classification of acetabular fractures include:

5 Elementary
5 Associated

5 Elementary

Judet and Letournel classification of acetabular fractures

5 Associated

Surgery: pelvis external fixator

Surgery Approaches to Pelvis

Anterior approach: Ilioinguinal and extended approach for visualization of both columns
Posterior approach: Kocher-Langenbach
Modified Stoppa approach

Surgery approach to symphysis pubis/anterior approach
(Pfannenstiel approach)

Skin incision: Horizontal incision 5-10 cm proximal to pubic tubercle
Subcutaneous dissection: Identify rectus fascia and make vertical incision in linea alba. Retract rectus. Additional exposure by releasing partially rectus insertion
Incision can be extended, Ilioinguinal approach

Surgery: Approach to Ilium/Sacroiliac Joint

Divide subcutaneous fascia in line with skin incision
Expose external oblique muscle
Divide interval between external oblique & gluteal muscles, elevate external oblique
Subperiosteal ilium elevation

ASSIS: Anterior Superior Iliac Spine, ITB: Iliotibial band

Surgery Posterior Approach to Hip/Acetabulum

Kocher-Langenbeck approach

Subcutaneous incision gluteus maximus and iliotibial band
Deep dissection: expose short external rotators by removing overlying fat covering (Sciatic nerve lies posterior to the gemelli & internal obturator muscles)
Detach gluteus maximus 1cm from the greater tuberosity insertion
Detach the external rotators and apply a stay suture in the piriformis tendon 1cm lateral to its insertion attachment point

Surgical Fixation of Associated Acetabulum Posterior Wall (± column) Fracture

Kocher-Langenbeck approach
Reduce fracture
ORIF plate and screw fixation

Surgical Fixation of Anterior Column

Anterior approach
Fracture reduction
ORIF plate and screw fixation

Surgery External Fixator Pin Sites

Pin placements:

15mm posterior to ASIS
Proximal superior part of AIIS

ASIS: Anterior superior iliac spine

AIIS: Anterior inferior iliac spine

Surgery External Fixator

Pin insertion: Anterior Inferior iliac Spine at 10-20° cranial and 20-30° medially.
X-ray guidance
Assemble ex fix

Complications Associated with Pelvic Fractures

Shock:

Shock due to blood loss from the pelvic fracture ± associated femur fractures (can cause 1-1,5l of blood loss) or secondary intraabdominal blood loss due to other associated injuries as caused by the high energy trauma associated with pelvic fractures.

Management:

Resuscitate with blood and fluids

Complications associated with femur fractures

Deep Vein Thrombosis (DVT)

DVT is characterized by clot formation within the deep veins.

Virchow described predisposition to vessel clot formation due to changes in the components within the blood circulation, flow change characteristics or vessel wall changes.

DVT predisposes to clot dislodgement with pulmonary spread that may cause sudden death.

Muscle contraction is important to allow blood flow within blood vessels

Deep Vein Thrombosis (DVT) Complication

DVT complication include clot dislodgment with clot spreading to the lungs

Management of DVT

Management includes prevention

Treatment

DVT stockings
Anticoagulation medication
Surgical venous filters in select cases

Download ASSIC Performance Fingerprint and Strength & Conditioning apps for guideline DVT prevention routines that includes travelling DVT prevention routine

Fat Embolism Syndrome

Fat embolism syndrome is a serious manifestation of fat emboli causing multiple organ dysfunction with lung hypoxia manifesting with shortness of breath with confusion. This may be the direct result of long bone fractures and/or secondary to intramedullary reaming of the femoral canal during the surgical procedure of femur nail and screw fixation.

The two theories causing the syndrome are either a mechanical release of the fat droplets into the venous system or a metabolic stress response causing the changes in the chylomicrons to form fat emboli.

Presentation:

Acute respiratory distress and confusion. Clinical examination will show a tachycardia, tachypnea and petechiae rash in the axillary region, conjunctivae or oral mucosa.

Management:

Prevention include early fracture stabilization within 24hrs
Supportive with maintenance of haemodynamic stability and respiratory support with mechanical ventilation with high levels of PEEP (positive end expiratory pressure)

References

Early management of severe pelvic injury (first 24 hours). P Incagnoli, A Puidupin, S Ausset, JP Beregi, J Bessereau, X Bobbia, J Brun, E Brunel, C Bulėon, J Choukroun, X Combes, JS David, FR Desfemmes, D Garrigue, JL Hanouz, I Plénier, F Rongieras, B Vivien, T Gauss, A Harrios, P Bouzat, E Kipnis. Anaesth Crit Care Pain Med. 2019 Apr;38(2): 199-207.
Pelvic trauma: WSES classification and guidelines. F Coccolini, PF Stahel, G Montori, W Biffl, TM Horer, F Catena, F Catena, Y Kluger, EE Moore, AB Peitzman, R Ivatury, R Coimbra, GP Fraga, B Pereira, S Rizoli, A Kirkpatrick, A Leppaniemi, R Manfredi, R Manfredi, S magnone, O Chiara, L Solaini, M Ceresoli, N Allievi, C Arvieux, G Velmahos, Z Balogh, N Naidoo, D Weber, F Abu-Zidan, M Sartelli, L Ansaloni. World Journal of Emergency Surgery (2017) 12:5.
Anterior approach to the sacroiliac joint for pelvic fractures: Technical note. G Riouallon, L Chanteux, P Upex, M Zaraa, P Jouffroy. Orthop Traumatol Surg Res. 2020 Sep;106(5): 845-847.
Fractures of the acetabulum: from yesterday to tomorrow. M Cimerman, A Kristan, M Jug, M Tomaževič. Int Orthop. 2021 Apr;45(4): 1057-1064.

Contributor:

Prof S Maqungo

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